Clinical Information Resources/ Evidence Based Practice Sandra A. Martin, M.L.I.S. Health Sciences Resource Coordinator Instructor of Library Services John Vaughan Library Room 305B –

Existing knowledge can prevent… Waste Errors Poor quality clinical care Poor patient experience Adoption of interventions of low value Failure to adopt interventions of high value Source: Sir Muir Gray, Chief Knowledge Officer of Britain’s National Health Service. Quoted on

Harmful practices once supported by expert opinion Source: Adapted from How to read a paper: the basics of evidence-based medicine. 4 th edition. By Trisha Greenhalgh Blackwell Publishing Time periodAccepted practiceShown to be harmful Impact on clinical practice From 500 bcBlood Letting1820Ceased in Thalidomide for morning sickness in early pregnancy 1960Withdrawn when first case report of severe malformations appeared From 1900Bed rest for acute low back pain 1986Still advised by some doctors 1960sBenzodiazepines for mild anxiety 1975“Diazepam” prescribing fell in 1990s due to severe dependence and withdrawal symptoms Late 1990sCox-2 inhibitors to treat arthritis 2004Withdrawn following legal cases in the US

Learning Objectives To familiarize students with the information retrieval process for evidence-based research & patient care To enable students to use synthesized/filtered/pre- appraised resources to answer clinical questions To enable students to use the 6S hierarchy of organization of evidence to plan search strategies

“EBM is a process of life-long, self-directed learning in which caring for our own patients creates the need for clinically important information about diagnosis, prognosis, therapy, and other clinical and health care issues.” Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2. Patient Concerns Life-long Learning Best research evidence EBM What is EBM?

“Evidence-based medicine is the integration of research evidence with clinical expertise and patient values.”best. Patient Concerns Clinical Expertise Best research evidence EBM What is EBM? Sackett, DL, Richardson, WS, Rosenberg, WMC, & Haynes, RB (1996). Evidence-Based Medicine: How to practice and teach EBM. London: Churchill-Livingstone.

Evolution of EBM in the Literature Term “evidence based medicine” coined by Dr. Gordon Guyatt at McMaster University Term first appeared in the literature in a 1991 editorial in ACP Journal Club Volume 114, Mar-April 1991, pp A-16 Seminal article by the Evidence-Based Medicine Working Group published in JAMA Volume 268, No. 17, 1992, pp Click on the “Evidence Based Medicine” tutorial from the Nursing web page to view a brief video of EBM history

Fundamentally new approach becomes widely recognized JAMA published a series of Users’ Guides to the Medical Literature that served as the first learning tools The first handbook, Evidence-Based Medicine: How to practice and teach EBM, by Sackett, et al, was published in Fourth edition published in 2010 Courses were developed in residency training and medical school curricula beginning in the mid-1990s EBM process has become basic in medicine, nursing, speech pathology, occupational therapy, other health care disciplines including psychology and the social sciences

Integration of EBM into medical school curricula patient-doctor courses

EBM Process – 5 Steps 1. ASK: Convert need for information into answerable question 2. ACQUIRE: Find best evidence to answer the question 3. APPRAISE: Critically appraise evidence for validity, impact, and applicability 4. APPLY: Integrate evidence with clinical expertise and patient values 5. ASSESS: Evaluate own effectiveness

New Approach Requires New Skills Clinical question formulation Search and retrieval of best evidence Critical appraisal of study methods to determine validity of results

Information Retrieval for Evidence Based Patient Care Using research findings versus conducting research Retrieving and evaluating information that has direct application to specific patient care problems Selecting resources that are current, valid and available at point-of-care Developing search strategies that are feasible within time constraints of clinical practice

Is All Evidence Created Equal? Small portion of medical literature is immediately useful to answer clinical questions Understanding “wedge or pyramid of evidence” is helpful in finding highest level of evidence High levels of evidence may not exist for all questions due to nature of medical problems and research limitations

As you move up the pyramid the amount of available literature decreases, but it increases in its relevance to the clinical setting. Source: Sackett, D.L., Richardson, W.S., Rosenberg, W.M.C., & Haynes, R.B. (1996). Evidence-Based Medicine: How to practice and teach EBM. London: Churchill-Livingstone.

Clinical/Foreground Questions Arise in patient care setting Fill gaps in clinical knowledge regarding  Diagnosis  Therapy/prevention  Prognosis  Etiology

Answers to Clinical/Foreground Questions Require:  precise information about complex issues  trustworthy clinical research data with direct application to patient problems 17

Well Built Questions include Elements of PICO Model P -Patient or population I - Intervention C -Comparison Intervention O - Outcome

Evidence Based Search Strategy 1. Includes search terms from the clinical question 2. Matches best study design for type of question 3. Retrieves answers at highest levels of evidence

Therapy/Prevention Questions What is the best available evidence regarding prevention of catheter associated urinary tract infections? In patients with urinary catheters [patient], are antibiotic coated catheters [intervention] versus standard catheters [comparison intervention] effective to reduce or prevent catheter associated urinary tract infections [outcome]?

1. Search Terms Catheter Antibiotic Urinary tract infection Prevention

2. Best Study Design for Type of Question Type of QuestionStudy Design Therapy/preventionRandomized controlled trials DiagnosisProspective cohort, blind comparison to a gold standard PrognosisCohort, Case Control, Case Series Etiology/HarmCohort, Case Control, Case Series

3. Highest Level of Evidence – 6S Hierarchy

Search First at Top Levels of 6S MEDLINE - major source of “primary” literature  Process of searching, selecting, evaluating original research is time consuming and requires critical appraisal skills Filtered/Synthesized/Evaluated resources - “secondary” literature  Speed application of evidence at “point-of-care”  Grade strength of treatment recommendations  Rate quality of research evidence

Point-of-Care Resources Evidence based summaries  Provide rapid access to concise information for clinicians at the point of care  Not a database of articles from books, journals, or guidelines  Original, current, summaries written by experts  Formal systems used to grade strength of recommendations and quality of evidence Available from Library Resources for Nursing web page  UpToDate  Joanna Briggs Institute

Summaries UptoDate –Evidence based summaries of over 10,000 topics in over 22 specialties –8,500 Treatment Recommendations –GRADE System used to score recommendations and strength of evidence –Updated continuously; Includes practice changing updates –Drug database; Patient education materials –The Gold Standard of evidence summaries

UpToDate GRADE System UpToDate GRADE System Guyatt GH, Oxman AD, Kunz R, et al. What is "quality of evidence" and why is it important to clinicians?. BMJ. 2008;336(7651): /bmj analysis pdf /bmj analysis pdf

UpToDate Evidence-Based Summary Targets Specific Clinical Question

JBI Full Text Summary

Synopsis of Syntheses Database of Abstracts of Reviews of Effects DARE –Search online in OVID –Part of OVID’s evidence based medicine reviews collection –Full text database contains “critical assessments” of systematic reviews published in various medical journals

Systematic Review Analyzes data from several primary studies to answer a specific clinical question Provides search strategies and resources used to locate studies Uses explicit methods to identify, select, and critically appraise relevant research and to collect and analyze data from the studies Statistical methods (meta-analysis) may or may not be used to analyze and summarize results Benefits: Limits bias and increases confidence in conclusions

Critical Assessment of Systematic Review

Syntheses Cochrane Database of Systematic Reviews (DSR) –Part of the Cochrane Library (1996) –Over 3,000 reviews & protocols (reviews in the making) –The Gold Standard of systematic reviews –Eyes & Vision Research Group Contains over 200 reviews –Full Text Available in Ovid

JBI Systematic Review

Synopses of Studies JBI –Contains Best Practice Information Sheets –Includes key issues/recommendations collected from a large volume of material –Based on results and recommendations of systematic reviews ACP Journal Club –Contains abstracts of studies selected by ACP editors as valid and clinically relevant –Part of OVID’s evidence based medicine reviews collection –Primary care focus

Not all topics fit the 6S Model High levels of evidence may not exist for all questions

Overviews and Individual Studies Resources:  Clinical Key for Nursing (Includes MEDLINE)  Ovid MEDLINE (tools for “precise” search strategies)  Science Direct – Good source for articles in health professions journals outside nursing (does not include MEDLINE)  eBooks and library print book collection 48

Clinical Key for Nursing “All in one” database with full text access to Elsevier journals and books in nursing 12 Content Types including MEDLINE, images & videos Access to information at all levels from topic overview to evidence-based data in one search Smart search engine matches first few letters of search word/words to relevant clinical content No complicated search strategies or Boolean connectors Easier than Google – but with reliable, evidence-based results

MEDLINE U. S. National Library of Medicine’s premier database. Contains over 20 million citations to journal articles in medicine, nursing, allied health, and basic sciences as they relate to health care Covers 1946-present Ovid and Clinical Key for Nursing include “user friendly” interface. Natural language processing of keywords eliminate complicated searches 50

Science Direct Elsevier’s database of peer reviewed journal articles (published by Elsevier) in both subscription and open access journals NSU subscribes to journals in life sciences, health sciences, and some physical sciences Does not include MEDLINE Use “Advanced Search” to limit results to subscribed and open access full text 51

Take Home Points Focused clinical question reveals your search terms and best type of studies Start your search at top of 6S hierarchy and work down (UpToDate, JBI) Be aware of the filters: levels of evidence, graded recommendations, speed of updating Look at more than one resource in the hierarchy. Findings may differ

Information is Ever Changing